Advancements of liver transplantation for hepatocellular carcinoma in Korea

Abstract

The Milan criteria are still considered the gold standard for patient selection criteria for liver transplantation in patients with hepatocellular carcinoma. However, those criteria may be too strict and thus exclude a significant number of patients who could benefit from liver transplantation. Based on this notion, many expanded selection criteria have been suggested. In Asian countries, where there is a serious shortage of deceased donor organs, living donor liver transplantation accounts for the majority of all liver transplant cases. Because living donor liver transplantation is not controlled by the public allocation system, the indications for living donor liver transplantation can be expanded. In Korea, living donor liver transplantation depends entirely on the discretion of the transplant team and the donor. Hence, Korean transplant centers have had a reasonable amount of experience with liver transplantation for advanced hepatocellular carcinoma. Experiences in Korea show that serum alpha-fetoprotein level, des-gamma-carboxy prothrombin level and positron emission tomography are very useful biomarkers in predicting tumor recurrence after transplantation. Tumors that show favorable levels of these biomarkers might not recur after transplantation despite being morphologically advanced. In addition, combination therapy with mammalian target of rapamycin inhibitors and sorafenib may improve survival even after tumor recurrence. Therefore, in Korea, living donor liver transplantation is considered even for cases of far advanced hepatocellular carcinoma if a recipient has no other effective treatment options and a well-informed donor wishes to willingly participate.

Surgical Outcome of Pulmonary Metastasectomy for Hepatocellular Carcinoma Recurrence in Liver Transplant Patients

“…In addition to liver resection, LT has become a definitive treatment for HCC, with studies reporting better long-term overall survival and disease-free survival with LT than with liver resection [ 14 ]. Moreover, criteria for LT have expanded [ 15 ]. Extrahepatic recurrence after LT is the most frequent cause of patient mortality, with the lungs being one of the most common sites of extrahepatic metastases [ 16 ].…”

Patient Selection by Tumor Markers in Liver Transplantation for Advanced Hepatocellular Carcinoma

“…Hence, most expanded criteria that have been suggested for DDLT showed longterm survival rates of >70%, not significantly inferior to those under the MC . However, LDLT differs from DDLT in that because LDLT is performed based on private relationships between the donor and the recipient, liver grafts are dedicated to only 1 potential recipient . Expanding the LDLT criteria for HCC would not result in decreased LT opportunities for patients with other etiologies, and thus, slightly lower expected survival could be acceptable in LDLT .…”

“…In their first study, they found that their patients with HCCs that met the MC had a 75% overall survival rate and an 83% recurrence‐free survival rate 4 years after LT . The MC justified LT for HCC by improving the longterm results to levels comparable with those of LT for nonmalignant diseases . Thus, the MC is undoubtedly the standard of choice for patient selection for LT for HCC.…”

“…Thus, the MC is undoubtedly the standard of choice for patient selection for LT for HCC. Nonetheless, various new expanded criteria for LT for HCC have been continuously proposed from transplant centers worldwide even in the post‐MC era . The University of California, San Francisco criteria and up‐to‐7 criteria are well‐known representatives .…”

Cellular Senescence and Their Role in Liver Metabolism in Health and Disease: Overview and Future Directions

“…Some liver transplant programs switch their immunosuppression protocol from tacrolimus to rapamycin in patients with high risk for HCC recurrence after transplantation. However and on retrospective studies, its effect on long term overall survival on patients after liver transplantation for HCC, have had conflicting results [39,40].…”